This document discusses compartment syndrome, including definitions, types, pathophysiology, etiology, clinical evaluation, diagnosis, management, complications, and treatment. It provides details on acute compartment syndrome and chronic compartment syndrome. It describes the anatomy of compartments in the arm, forearm, hand, thigh, leg and foot. Diagnosis involves clinical examination and measurement of compartment pressures. Treatment involves surgical or non-surgical management depending on the severity of presentation and measurements. Complications can include muscle necrosis, contractures, reperfusion injury, neurovascular issues, infection and death if not properly treated.

1. Ext.Sawanya Saowapap
Hadyai hospital

2. Compartment Syndromes
Definition
Types
Pathophysiology
Etiology
Clinical evaluation
Diagnosis
Management
Complications
2

3. Definition
An elevation of the interstitial pressure in a closed
osteofascial compartment that results in
micrvascular compromise.
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
3

4. Types of compartment syndrome
Acute compartment syndrome (ACS)
 medical emergency
 caused by a severe injury
 can lead to permanent muscle damage.
Chronic compartment syndrome (CCS)
 known as exertional compartment syndrome
 not a medical emergency
 most often caused by athletic exertion.
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
4

5. Pathophysiology of ACS
The vicious cycle of
Volkmann's ischemia
 Increased intracompartmental P
 increases local venous P
 narrowed AV perfusion gradient
 compartment tamponade
 decrease capillary blood flow
 O2 deprivation
 local tissue necrosis
 nerve injury and muscle
ischemia
S. Terry Canele. Campeell’s Operative
.Orthopedics Volume 3. 11th edition
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
5

6. Pathophysiology of ACS
Whiteside' Theory:
The development of a compartment syndrome also depends
on
MPP = DBP(Diastolic BP) – CP(Intracompartment P)
Muscle perfusion pressure(MPP) < 30 mmHg
 Tissue hypoxia
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
6

7. Etiology of ACS

Decrease compartment size
Tight dressings/closure of fascial defect
 External pressures : casts, splints , burn
eschar, lying on limb for long period,
lithotomy position

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
7

8. Etiology of ACS
 Increase compartment contents
Fractures : the most common are
•In adults --- closed and open tibial shaft fx ,
distal radial fx
•In children --- radial head or neck fx ,
supracondylar fx , forearm fx
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
8

9. Etiology of ACS
 Increase compartment contents
• Hemorrhage -- vascular injury, coagulopathy
• Muscle edema -- severe exercise , crush injury
• Burn -- increase capillary permeability
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003
9

10. Increase compartment
contents
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. 10
.Philadelphia, Pensylvania. Mosby Elsevier, 2003

11. Clinical Evaluation of ACS
Clinical presentations :
Swelling/ Tightness of compartment
Inappropiated and uncontrolled pain
Severe pain at rest or passive stretching
Pallor/Cyanosis
Hyperesthesia/Paresthesia
Paralysis : full recovery is rare
, www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site
.Duke Orthopaedics : North Calorina, 2013 11

12. Clinical Evaluation of ACS
Physical examination :
 Pain at compartment on passive stretching :
test each compartment separately
Thigh : - anterior compartment - passive knee flexion
- posterior compartment - passive knee extension
- medial compartment - passive hip abduction
 Hyperesthesia/Paresthesia
Peripheral pulses absent - amputation usually inevitable
, www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site
.Duke Orthopaedics : North Calorina, 2013 12

13. Measurement of
Compartment pressures
Indications : High risk injuries in
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
Technique : performed each compartments at close to the fracture
site as possible (highest pressure) or maximal swelling area
, www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site
.Duke Orthopaedics : North Calorina, 2013 13

14. Measurement of
Compartment pressures
Devices
Stryker hand-held system
Stryker slit catheter
, www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site
.Duke Orthopaedics : North Calorina, 2013 14

15. , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 15

16. Early management of ACS
Remove cast/bandage
Positioning of the limb at the level of the heart
- Do not elevate the affected limb
 decreases arterial pressure
IV hydration
Oxygen supplement
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 16

17. Early management
reevaluation&
S. Terry Canele. Campeell’s
.Operative Orthopedics Volume 3
, 11th edition. Philadelphia
.Pensylvania. Mosby Elsevier, 2003

18. Treatment
Nonoperative
observation
 delta
p > 30 mmHg, no clinical presentation of compartment
syndrome
Operative
emergent fasciotomy
 Positive
clinical presentation
 CP = 30-45 mm Hg
 delta p < 30 mmHg
 Contraindications : Missed compartment syndrome
(Various stage of muscle infarction)
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 18

19. Anatomy of Compartments
Arm 2 compartments
Forearm 4 compartments
 Hand 4 compartments
Thigh 3 compartments
Leg 4 compartments
Foot 9 compartments
19

20. 2 Compartments of arm
1. Anterior
1. Biceps,Bracialis
2. Musculocutaneous n.
3. Brachial a.
2. Posterior
1. Triceps
2. Radial n.
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013 20

21. ”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
21

22. 4 Compartments of forearm
most commonly affect volar
1. Mobile wad
: Brachioradialis,
Radial n
2,3. Dorsal superficial
&deep
:Posterior interoseous n & a
Dorsal incision
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
4. Volar superficial
&deep
:Median and Ulnar n.
Radial a., Ulnar a.,
ant. interosseous a.
22

23. 10 Compartments of hand
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
23

24. 3 Compartments of thigh
 Anterior
femoral
n
quadriceps
sartorious
 Posterior
sciatic
n
hamstrings
 Medial
obturator
adductors
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
24
n

25. S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 25

26. 4 Compartments of leg
1. Anterior
: Tibialis anterior, EDL,EHL
Peroneus
2. Posterior-Superficial
: Gastrocnemius, soleus,
plantaris
3. Posterior-Deep
: FDL, FHL,Popliteus,
Tibialis posterior, Tibial a,v,n.
4. Lateral
: Peroneus longus and
brevis,peroneal n
26

27. ”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
27

28. ”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
28

29. 9 Compartments of foot
”Karafsheh.MD, “Compartment Syndrome
.Mark on www.Orthobullets.com, Havard university, 2013
29

30. Dorsal dual incision
Medial incision
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013
30

31. Fasciotomy - post op care
Skeletal fixation can all be applied at time of initial surgical
decompression
After decompression care : sterile dressing (saline soaks ),
splinting in functional position
Return to OR for 2nd look in 2-5 days
- If no muscle necrosis  the skin is loosely closed.
- If closure is not accomplished
 Debridement after another 72- h interval
 Skin closure or skin grafting
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 31

32. Complications of ACS
Myonecrosis : after an ischemic insult of > 8 hrs.
Treatment
fasciotomy + debridement of the muscles + neurolysis
may lead to myoglobinuria and eventually renal
failure. Diuresis ( by mannitol,diuretics or IV fluids )
should be prompted to increase the tubular flushing
and eliminate the proteinaceous material
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 32

33. Complications of ACS
Volkmann ischemic contracture : myonecrosis replaced
with fibrous tissue  myotendinous adhesion formation.
Treatment
 Non-surgical (physiotherapy & bracing involve the joints)
 Surgical




contracture release,
nerve compression release,
amputation
reconstruction with tissue transfers
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 33

34. Complications of ACS
 Reperfusion syndrome : influx of myoglobin, potassium, and
phosphorus into the circulation
 characterized by hypovolemic shock and hyperkalemia
Evaluation :
 Fluid
loss, Shock
 Acidosis
 Hyperkalemia
 Myoglobinuria, Renal failure : need fluid 12 Lt over 48-hour
Management :
 Prioperative
hydration
 Mannitol
 Bicarbonate
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 34

35. Complications of ACS
Neurovascular injury
Infection
Amputation
Death
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calorina, 2013 35

36. 36

37. Chronic Compartment Syndrome
Known as exertional CS, recurrent CS and subacute
CS
 Typical patient is young (20-30s) athlete (long
distance runner)or military recruits
Occur mainly in the lower limb
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 37

38. Pathophysiology of CCS
Not yet fully understood
Probably from increased muscle relaxation pressure
during exercise
 decreased muscle blood flow
 ischemic pain and impaired muscle function
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 38

39. Physical Exam in CCS
Exercise –induced pain
Tenderness over the compartment
Bilateral involvement is common ( up to 82% )
Fascial hernias ( 39% in one of the studies )
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 39

40. DDx of CCS
Periostitis
Entrapment of the superficial peroneal nerve
Tendinitis of the posterior tibial tendon
Stress fracture of tibia
Intermittent claudication
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 40

41. Work up of CCS
Plain x-rays : will show 90% of stress fx
Bone scan : diffuse uptake ……..periostitis
localized uptake……stress fx
Tinel test : may be positive in superficial peroneal
nerve entrapment
NCS : could be helpful
MRI : promising results reported
Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional
Compartment Syndrome” Podiatry Today Volume 22 ,2009
41

42. Diagnosis of CCS
 Intracompartmental testing is the hallmark of
1)
2)
3)
diagnosis (as reported by Pedwotiz et al ) :
Pre-exercise resting pressure of 15 mm Hg or
more.
Pressure of 30 mm Hg 1 minute after the exercise.
Pressure of 20 mm Hg or more 5 minutes after the
exercise.
Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional
Compartment Syndrome” Podiatry Today Volume 22 ,2009
42

43. Treatment of CCS
 Non-operative :
 NSAIDs
 Electrostimulation
 Muscle relaxants
 Ultrasound
 Cessation or significant reduction of athletic activities
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 43

44. Treatment of CCS
 Operative treatment


Single incision fasciotomy
Double incision fasciotomy
 After surgery :
Early ROM exercises are encouraged.
Weight bearing on crutches is allowed on POD1.
Light jogging is allowed at 2-3 weeks if no swelling or
tenderness
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003 44

45. References
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th
edition. Philadelphia, Pensylvania. Mosby Elsevier, 2003.
Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site :
www.wheelessonline.com, Duke Orthopaedics : North Calorina,
2013.
Mark R. Brinker. Fundamental of orthopedics. Bathesta,
Maryland : University of Texan Health Sciences Center, 1992.
Robert J. Duggan. “ How To Diagnose And Treat Chronic
Exertional Compartment Syndrome” Podiatry Today Volume 22 ,
2009
Mark Karafsheh.MD, “Compartment Syndrome” on
www.Orthobullets.com, Havard university, 2013.
45